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�,� TM� ��,�,��x �^_ '�� ;� <br /> � `'* � ,. �'�� „�"� � <br /> , � w � � �; � ��.'�� r <br /> ��. ���r d �,. , �, _ �i� a� �i`4 il�O � '� Q <br /> � � � <br /> � �, E� <br /> � ' Building Permit A►ppiica�io� for IVeainte�a�ce / Reno�a�ion � 4 <br /> �� <br />'�� (windows, doors, si�iing, re-roof, efc.) <br /> Mailin Address: �� <br />_�: ��v 0,� PO Box 66 Permit number: vZ0 /'j —CJO d� � <br /> Crystal Bay, MN 55323-0066 Date received: � �J /�� � <br /> �O � o � <br /> ��a �'a y�;, s, Street Address: Received by: � <br /> �Y ;1 y. <br /> �'�n �,�'a„ �� 2750 Kelley Parkway Plan review fee: � <br /> L�s �"r�w Orono, MN 55356 �'� <br /> kEsxo4` „ <br /> Total Fee: ��o� , (P 9 � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us a� <br /> ;,` This application form must be completed in full and all required information must be submitted. ,� <br /> Incompiete applications will be returned. (Please print) � <br /> ` GENERAL INFORMATION: I <br />� ' Job Site Address: ��� �r� ,, l�.v� �����l�V�- � <br />`� Will this be a Parade of Homes, Remod�le s Show se Home or other Disp�ay Home? ❑ Yes ��No ' <br />�"' !f yes,a special event permit is required with Poiice Department and City Counci/approval 60 days prior to the event. Shuttle bus service wilf be <br /> � required unless appficanf demonstrates sufficient on-site parking is availab/e. Non-permifted events will nof be allowed. ;$ <br /> �� <br /> CONTRACTOR/APPLICANT INFORMATIO�l: � <br /> Name: <br /> State License# Expiration Date: � <br /> Lead Certification Number: Expiration Date: � <br /> ' (for work on homes fhat were consfructed prior tSy 978 �;� <br /> � Phone: (office) (cell �° <br /> ) �,� <br /> Maifing Address: City: ZIP: �� <br /> .,� <br /> `' Contact Person: / � Applicant is: Contractor / Homeowner (Cirde One) �� <br />��� Email and/or Fax: � `�� <br /> / �� <br /> PROPERTY OWNER NFORMAT\ N: ��; <br /> Name: �� , �rl-- �:'� <br /> `� Phone (day): r�-Z-3 � P` <br /> " Address: ^ �� <br /> �. �21� �D ��� 2.2--Crt �.o. City: ��(,rl�� ZIP: .5�.�.� f �' <br /> ; <br /> '' Email and/or Fax �_-� ���� � Co�„` `�' <br /> i��c � aw.lj�nsv� . Y '4<'s"�' �: <br /> �� <br />" ` PROJECT INFORMATION: :� <br /> Type of Project: Any earth movement may require _�fi; <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: � <br /> R� Minnehaha Creek Watershed District(MCWD) x <br /> ❑ Re-roof, asphalt ❑ Re air �� <br />�;� p ❑ Storm Damage 18202 Minnetonka Blvd ;�.; <br /> ❑ Re-roof, cedar ❑ Restorafion ❑Water Qamage Deephaven, MN 55391 ; <br /> ` Phone: 952-471-Q590 ` <br /> "L�' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify} Fax: 952-471-0682 "4 <br /> � ❑Window(s) www.minnehahacreek.orq :} <br /> W� <br /> �;rs <br /> Y� <br /> �� Overall Project Dsscription: , 5;��� ��, �,y ;� � <br /> Esfirnated Construction ValuaEion of Project(excfuciing land) $"Z.ac�o '"� <br /> �� <br /> �": APPLICANT ACKNOWLEDGEMcNT: �w <br /> ;.: <br /> ��: • Agrees to provide all information required or requested by fhe Building Department; �� <br /> �` i <br /> � <br /> • Certifies that the information supp(ied is true and correct to the best of his/her knowledge. The appficant recognizes that they ! � <br /> �� are solely responsibie for submitting a complete appiication being aware that upon failure to do so, the staff has no alternative <br /> �., <br /> but to reject it until it is complete; r;� <br /> • Some or alf of the information that you are asked to provide on this appfication is classified by State law as either private or <br /> confidenfial. Private data is information which generally cannot be given to the public but can be given to the subjecf of the ,q, <br /> �y data. Confidential data is information which generally cannot be given to either the pubfic or the subject of the data. Our E; <br /> purpose and intended use of this information is to annualfy update our records and records of other governmental agencies � <br /> re �ired b law. If vou refuse to su pl the information,the a pfication mav not be issued. T� <br /> � �;j <br /> AppficanYs Signature: `—� Qate: � Z-- �, <br /> r„� <br /> . <br /> Last Updated: 08-09-2011 , <br /> , <br /> :., <br /> i � , <br /> �,, a,� �, ,. , � �,. .. ,_ , . .,_ .. � <br />